COVID-19 Self Reporting

COVID-19 Self Reporting Tool

Please fill in all of the fields of information requested below.  If you have more than one child to report, please exit this form when finished and submit a new form for each child.  Someone from the school will reach out to you to verify that the information provided is accurate. The information provided will determine actual COVID-19 status as it pertains to their participation in on-campus learning and activities.   

Name of person making the report.
(This will be the person we contact for verification.)

Phone number of reporting person. 

If there is an alternate number, please enter it in the blank below.  

Email Address for person making the report:

 

Information of student(s) involved in the report:

Student 1

Name                    Campus        Grade           

        

1) Are you reporting a positive result for COVID-19 for Student 1?  :

Yes - If answering yes, please answer the questions below. 

No - Please skip to question 2

 

 Date when symptoms started 

 If asymptomatic, date of positive test 

 Practioner name (where test was administered)

Physical address 

Names of HISD staff and students you were in close contact (as defined by the HISD Strong Start plan) with anytime during the 48 hours prior to the symptoms (for symptomatic cases) or positive test (for asymptomatic cases).

 

2) Reporting close contact to a COVID-19 positive case:

Yes - Please answer the questions below.

No - Please skip to question 3. 

Tell us if it is outside of school or from school (including off-campus lunch, school-related activities).

At School
Who were you a close contact to? 

Outside of School
  If outside of school, are you able to quarantine away from the case for 14 days?  Yes    No

What was your last date of contact? (if in your household, what's the last day of close contact - you must quarantine away from the positive case). 

Have you had any symptoms? Yes    No

 

3) Reporting that someone in your household is symptomatic and has pending test results:

Yes     No

If the answer is yes:

- Stay off campus and do not attend school-related activities until a negative test result is returned.

- If test results are positive, complete the survey again.  If test results are negative, contact Kendra.bennett@henrietta-isd.net to let the school know.

If you have any additional information you would like to share with us, please use the box below.

 



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